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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOR 2009, STOCKTON, CA 95201 2ERK11 EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) Application is hereby made to San Joaquin County for a-permit to construct and/or install the work herein described. Thi6 application. is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. t1 ob Address A/ i� t� City Lot Size/Acreage _ � - ------ ---- Owner's Name G�!q � cG Address Phone Contractors r 1 ( } IC _ LAddress 1�� l 7 c�5'�turtmr� License No. —�� Phone — TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing fa Domestic/Private ❑ Gravel Pack' ❑ Tracy Type of Casing Specifications I'I Public CI Other n Delta Depth of Grout Seal Type of Grout I I Irritation =.Approx.'Depth l-I Eastern Surface Seal Installed by Repair Work Done. 0 Type of'Pump H,P, State Work Done _ Well Destruction ❑ "Well Diameter Sealing Material & Depth Depth �� Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION i I DESTRUCTIO (No septic system permitted if public sewer is o f I available within 200 feet.) �y Installation will serve: Residence! Commercial_ Other \] Number of living units:' Numberofbedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg. -L Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' Method of Disposal Distance to nearest: Well Foundation Property Line ' LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Properly Line SEEPAGE PITS 11 Depth ) Size Number SUMPS 0 Distance to nearest: Well Founda_tion� Property Line DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not f employ any person in such manner as to become subject to workman's compensation laws of Califorria." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." I ' The applicant must call for all required ins otions. Complete drawing on reverse side, f Signed ?( y:� - - -�" '^ - -- -Title N Date: �- ,:3 DEPARTMENT USE ONLY ' Application Accepted by Date Y 1 Area Pit or Grout Inspection by ate Final Inspection by Date I i Additional Comments: I Applicant - Return all copies to: t>an Joaquin County Public Health -Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y OATS PERMITNO. ♦ EH 13.24(REV.1rR51 EH A-26